Which imaging or diagnostic tests are recommended for evaluating thickened endometrial lining in postmenopausal women?

Recommended imaging and diagnostic tests for evaluating a thickened endometrial lining in postmenopausal women include:

• Transvaginal ultrasound scan as the first-line imaging modality to assess endometrial thickness and detect abnormalities in the uterine cavity. This is preferred over transabdominal ultrasound or MRI due to better resolution for endometrial assessment.
• Outpatient hysteroscopy is recommended if there are symptoms suggestive of endometrial pathology (e.g., persistent bleeding) or if risk factors for endometrial pathology are present. Hysteroscopy allows direct visualization of the endometrial cavity and enables targeted biopsy.
• Endometrial biopsy should be considered at the time of hysteroscopy for women at high risk of endometrial pathology, such as those with persistent irregular bleeding, obesity, or tamoxifen use. Blind endometrial biopsy is not recommended.
• Pelvic ultrasound (transvaginal preferred) is also used to evaluate the uterus and exclude other causes such as fibroids or adenomyosis.
• MRI is not recommended as a first-line diagnostic tool for heavy menstrual bleeding or endometrial thickening but may be considered if ultrasound findings are inconclusive or further characterization of fibroids or adenomyosis is needed.

These recommendations align with NICE guidelines on heavy menstrual bleeding and endometrial pathology assessment ¹.